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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320218
Report Date: 09/21/2021
Date Signed: 09/21/2021 02:45:08 PM

Document Has Been Signed on 09/21/2021 02:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:GRANDVIEW GUEST HOMEFACILITY NUMBER:
198320218
ADMINISTRATOR:SANTOS, JENNICE-RAE RUTAFACILITY TYPE:
740
ADDRESS:2444 235TH STTELEPHONE:
(310) 782-5045
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 0DATE:
09/21/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:LICENSEE COTA CABRALTIME COMPLETED:
12:00 PM
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On 09/21/2021 around 10am Licensing Program Analysts (LPA) Jose Calderon conducted an announced face to face visit with Licensee Coty Cabral for purpose of a pre-licensing evaluation. The requested capacity is for 6 adult residents of which there is 1 ambulatory/ 5 non-ambulatory Adult Residents.

Facility is a 4 bedroom, 2 bathrooms, one-story house. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a backyard with a covered patio for shade. The patio contained 1 small table and 3 chairs. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Residents Bedrooms: All 3 Bedrooms are for ambulatory/non-ambulatory clients. Bedroom’s #1 and #2 and #3 has one bed each, one chair, one-night stand, one lamp. There are dressers within the closet for each resident. Bedrooms #1, #2 and #3 all comply with the requirement of 8 cubic feet of space. Bathroom: Have a working toilet, wash basins, and walk-in shower. Bathroom #1 shower is missing grab bars, but licensee states bathroom #1 is for ambulatory only residents. LPA observed adequate lighting in hallway leading to bathrooms. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in hall closet.

Emergency Phone Numbers, Exit Plan & Menu: The telephone system is a land line and operable. Emergency Disaster Plan and "See something, say something Let Us Know" were missing. Fire Extinguisher 1 mounted on the wall in hallway next to the front door.


Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet located in the kitchen area. Food supply is not adequate; no food was found in the kitchen refrigerator and 7 days of dry food was found in the kitchen pantry which consisted of dry pasta, canned foods.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GRANDVIEW GUEST HOME
FACILITY NUMBER: 198320218
VISIT DATE: 09/21/2021
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Smoke Detectors: 4 hard wired smoke detectors are battery and electric. operated & working. Carbon monoxide detector located and mounted in the hallway is operational. Appliances: Gas Stove, oven, microwave, washer, and dryer working. Refrigerator in the kitchen has a measured temperature of at least 41 degrees Fahrenheit for appropriate food storage. Freezer is at 19 degrees Fahrenheit. The residence is equipped with central air and heat and each client bedroom is individually climate controlled. Toxins: Locked/stored in the storage room located in the kitchen. Water Temperature: Bathrooms water temperature tested in #1 at 105 F. and #2 106 F. degrees, kitchen sink temperature tested at 115 F degrees. Medications, First-Aid Kit & Book: Medication administration records storage area, and first aid kit has been inspected, which are stored in locked kitchen cabinet adjacent the refrigerator, available for staff use but inaccessible to clients.

Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use. LPA did not observe any pet or bodies of water at the facility. LPA did not observe delayed egress, chain locks or dead bolts on exits. LPAs did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits. Pool/Jacuzzi & Pets: LPA did not observe any pet or bodies of water at the facility. Fire clearance: Fire Clearance was approved on 09/14/2021 for 2 ambulatory/4 non-ambulatory clients with no special instructions. LPA did not observe delayed egress, chain locks or dead bolts on exits. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GRANDVIEW GUEST HOME
FACILITY NUMBER: 198320218
VISIT DATE: 09/21/2021
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During the pre-licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected:

· Bedroom #1, missing a dresser
· No food was found inside refrigerator
· No 30-day supply of PPE’s were found

If additional time is required to complete noted items to correct, then the applicant will request an extension prior to the due date.

Component III: (09/21/2021) about how to operate the facility within substantial compliance was not reviewed by the licensee at this time. LPA Calderon emailed component 3 to licensee for her review

During the pre-licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected, and proof of correction shall be emailed to LPA Jose Calderon by 09/24/2021. If additional time is required to complete noted items to correct, then the applicant will request an extension.

An exit interview was conducted, and a copy of this report has been furnished to the applicant by hand. Accordingly, LPA Jose Calderon will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC809 (FAS) - (06/04)
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